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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1. PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  12

Inc Town:  IRVINGTON

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5312

File No.  17196

Registered No: 7 

2. FULL NAME:  BEAUCHAMP, OLLIE RAY

PERSONAL AND STATICAL PARTICULARS

3. SEX:  FEMALE

4. COLOR OR RACE:  WHITE

5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6. DATE OF BIRTH:  JUL 14, 1908

7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  3 / - / 12

8. OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  

9. BIRTHPLACE:  GRAYSON COUNTY

10. NAME OF FATHER:  NOT LISTED

11. BIRTHPLACE OF FATHER:  NOT LISTED

12. MAIDEN NAME OF MOTHER:  OLLIE BEAUCHAMP

13. BIRTHPLACE OF MOTHER:  GRAYSON CO, KY

14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  C. STILL

(Address)  IRVINGTON

15. Filed  JUL 31, 1911

REGISTAR:  D.W. HENRY

MEDICAL CERTIFICATE OF DEATH

16. DATE OF DEATH:  JUL 31, 1911

17. I HEREBY CERTIFY, That I attended deceased from (date):  JUL 24, 1911 to JUL 31, 1911

That I last saw him/her alive on (date):  JUL 31, 1911

And that death occurred on the date stated above at (time AM/PM):  8 PM

THE CAUSE OF DEATH was as follows:  OVERDOSE OF OIL WORMSEED

 

(Duration)   Years:     3       Months:     0       Days:  16

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.): S.P. PARKS 

Date:  AUG 1, 1911

Address:  IRVINGTON

18. LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)

At place of death (yr, mo, da.):  

In the State (yr, mo, da):  

Where was disease contracted,  if not at place of death?  

Former or usual residence:  

19. PLACE OF BURIAL OR REMOVAL:  BEAUCHAMP

DATE OF BURIAL:  AUG 2, 1911

20. UNDERTAKER:  

ADDRESS:  

 

TRANSCRIBER’S NOTE:  STRAY LINE ACROSS “OLLIE” APPEARS TO INCORRECTLY DELETE INFO.
 
 


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************